Credentialing Specialist

About the role

At Triple-S, the Credentialing Specialist supports credentialing and re-credentialing processes and contributes to strategies for maintaining network adequacy. The role independently performs tasks using knowledge of policies, procedures, and general methods of operation. It involves collecting, researching, analyzing, organizing, and presenting information, making recommendations for higher-level review, and channeling unusual situations to a supervisor.

Triple-S serves more than 1 million consumers in Puerto Rico through its Medicare Advantage, Medicaid, Commercial, Life, and Property & Casualty businesses.

Responsibilities

• Review provider applications to ensure they are complete and include documentation required for the provider specialty, provider type, or contracted services.
• Apply federal regulatory requirements (CMS), local government requirements (ASES), URAC Accreditation, and company policies and procedures in credentialing and re-credentialing processes.
• Coordinate the collection of information and necessary documents from internal and external primary and secondary sources.
• Collaborate and participate in functions related to the procurement process, credentialing, and strategies to maintain network adequacy.
• Research and analyze information, make recommendations for higher-level review, and refer unusual situations or situations not covered by procedures to a supervisor.

Datos clave

• The role is with Triple-S in Guaynabo, Puerto Rico.
• Reviews provider applications and required documentation for credentialing and re-credentialing.
• Coordinates information and documents from internal and external primary and secondary sources.